- Email: [email protected]
October Consultation # 8
1686
CONSULTATION SECTION
reduce postoperative inflammation. Once I ascertain that the paracenteses are secure, I would measure the IOP with an intraoperative Barraquer tonometer, leaving the pressure between 15 mm Hg and 22 mm Hg. One oral acetazolamide (Diamox) sequel would be prescribed immediately postoperatively. Lisa Brothers Arbisser, MD Bettendorf, Iowa, USA Rock Island, Illinois, USA Salt Lake City, Utah, USA
proposition, but use of viscodissection may facilitate this approach. The PFC should not be left in the eye for an extended period, so I would perform the operation in conjunction with a PPV. This would be performed by a vitreoretinal colleague to remove the PFC from the posterior chamber. Endolaser or a buckling procedure may be warranted depending on the status of the retina. Tim Johnson, MD Iowa City, Iowa, USA
Dr. Arbisser has honoraria and research grants from Alcon and AMO.
- As important as the surgical approach is the discussion of expectations and risks with the patient. The patient must understand the risk for recurrent iritis and retinal detachment if the decision is made to proceed with an operation. My sense is that cosmetics are important to her, but this should be balanced against issues of visual function. I would also involve the vitreoretinal surgeon in the decision-making process because removal of the PFC is a consideration. Any surgical intervention carries the risk for reactivating the uveitis. If the patient elects to proceed with surgery, I would initiate topical therapy (eg, prednisolone acetate [Pred Forte] 4 times a day or every 2 hours for 1 to 2 weeks before surgery) and deliver sub-Tenon’s or intraocular triamcinolone acetate (Kenalog) at the time of surgery. Postoperatively, an extended course of steroids and probably an NSAID would be appropriate. Despite the statement in the case report that the IOL is in the capsular bag, it is obvious that the inferior portion of the optic is outside the bag. The photographs do not allow visualization of the anterior capsule, but I presume the initial capsule tear was larger than the optic and the anterior and posterior capsules are now fused beyond the edge of the optic. Options for dealing with the IOL include repositioning it or an IOL exchange. Given the previous Nd:YAG laser capsulotomy, I would favor leaving the existing IOL. I would perform careful synechialysis to relieve the adhesions. Use of viscodissection could help reduce the need for blunt and sharp dissection and thus minimize the risk for postoperative uveitis. If the anterior capsule opening were smaller than the optic, it would be useful to reopen the bag to allow complete optic capture within the bag. However, I think the opening is too large in this case. To prevent future optic capture, the pupil should be constricted with interrupted polypropylene sutures or an iris cerclage. An alternative that avoids suturing the iris would be to exchange the IOL and place an IOL with a larger optic (eg, AcrySof MA50BM with 6.5 mm optic) in the sulcus. An open posterior capsule makes this a riskier
- This patient’s unfortunate situation is multifactorial. Clearly, her downgaze complaints stem from the PFC in the anterior chamber. This can be addressed by removal, most preferably at the slitlamp, before other interventions, as the PFC will likely migrate in the posterior segment with the patient in the reclining position and would require a combined approach with the vitreoretinal team to remove. With a small retained bubble posteriorly, a combined vitreoretinal and anterior segment approach is reasonable, although it often comes with logistical challenges. The recurrent iritis might be exacerbated by the sharp anterior edge of the AcrySof MA30BA IOL rubbing against the iris surface. This could be addressed by synechialysis, performed bluntly or using intraocular 23-gauge microscissors, as needed, combined with repositioning the IOL optic through the posterior capsule opening, IOL exchange for a round anterior edge IOL, or both. Pupil cerclage would prevent subsequent optic capture of the iris. The reflections off the anterior surface of the IOL may be less cosmetically disturbing with a pupil repair procedure, reducing the aperture by pupil cerclage (or imbricating) sutures, IOL exchange, or both. The AcrySof MA30 series IOLs had only 5.0 diopters of power on the anterior surface and thus had maximum reflectivity. Selection of an IOL that has a higher amount of power on the anterior surface would reduce the reflection from the third Purkinje–Sanson image, reducing the perceived reflection. Alternatively, an IOL with a lower index of refraction would also mitigate this cosmetic issue, although I would be reluctant to place a silicone-based IOL in an eye with a history of retinal detachment and iritis. Whether the altered anterior surface of a presbyopia-correcting multifocal IOL would reduce the cosmetic reflections has not been studied, although it is an interesting potential speculation to discuss with the patient if she is otherwise inclined toward such an IOL. The cataract in the fellow eye should be addressed only after the issues in the first eye have been satisfactorily resolved. In the second-eye cataract surgery,
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007
CONSULTATION SECTION
1687
all efforts should be directed at placement of a posterior chamber IOL within the confines of the capsular bag, with the capsulorhexis margin overlapping the edge of the IOL. Intraoperative use of carbachol (Miostat) will keep the pupil small for the first few days. Because synechias typically form only to the capsule and not the optic, keeping the pupil margin only over the optic surface for the first postoperative days, when inflammation is highest, will reduce the chance for posterior synechia formation in the second eye.
- In this interesting case, I would start by treating the right eye. First, I would remove the PFC bubbles in the anterior chamber by aspiration with (or without) the help of an OVD. This should be fairly easy. At the same time, I would reposition the IOL and use Miostat intracamerally. After a period of stabilization (8 to 12 weeks), I would recommend phacoemulsification and IOL implantation in the left eye with a close follow-up and higher topical steroid doses for a longer period until vision stabilizes.
Michael E. Snyder, MD Cincinnati, Ohio, USA
Gu¨nther Grabner, MD Salzburg, Austria
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007
CONSULTATION SECTION
reduce postoperative inflammation. Once I ascertain that the paracenteses are secure, I would measure the IOP with an intraoperative Barraquer tonometer, leaving the pressure between 15 mm Hg and 22 mm Hg. One oral acetazolamide (Diamox) sequel would be prescribed immediately postoperatively. Lisa Brothers Arbisser, MD Bettendorf, Iowa, USA Rock Island, Illinois, USA Salt Lake City, Utah, USA
proposition, but use of viscodissection may facilitate this approach. The PFC should not be left in the eye for an extended period, so I would perform the operation in conjunction with a PPV. This would be performed by a vitreoretinal colleague to remove the PFC from the posterior chamber. Endolaser or a buckling procedure may be warranted depending on the status of the retina. Tim Johnson, MD Iowa City, Iowa, USA
Dr. Arbisser has honoraria and research grants from Alcon and AMO.
- As important as the surgical approach is the discussion of expectations and risks with the patient. The patient must understand the risk for recurrent iritis and retinal detachment if the decision is made to proceed with an operation. My sense is that cosmetics are important to her, but this should be balanced against issues of visual function. I would also involve the vitreoretinal surgeon in the decision-making process because removal of the PFC is a consideration. Any surgical intervention carries the risk for reactivating the uveitis. If the patient elects to proceed with surgery, I would initiate topical therapy (eg, prednisolone acetate [Pred Forte] 4 times a day or every 2 hours for 1 to 2 weeks before surgery) and deliver sub-Tenon’s or intraocular triamcinolone acetate (Kenalog) at the time of surgery. Postoperatively, an extended course of steroids and probably an NSAID would be appropriate. Despite the statement in the case report that the IOL is in the capsular bag, it is obvious that the inferior portion of the optic is outside the bag. The photographs do not allow visualization of the anterior capsule, but I presume the initial capsule tear was larger than the optic and the anterior and posterior capsules are now fused beyond the edge of the optic. Options for dealing with the IOL include repositioning it or an IOL exchange. Given the previous Nd:YAG laser capsulotomy, I would favor leaving the existing IOL. I would perform careful synechialysis to relieve the adhesions. Use of viscodissection could help reduce the need for blunt and sharp dissection and thus minimize the risk for postoperative uveitis. If the anterior capsule opening were smaller than the optic, it would be useful to reopen the bag to allow complete optic capture within the bag. However, I think the opening is too large in this case. To prevent future optic capture, the pupil should be constricted with interrupted polypropylene sutures or an iris cerclage. An alternative that avoids suturing the iris would be to exchange the IOL and place an IOL with a larger optic (eg, AcrySof MA50BM with 6.5 mm optic) in the sulcus. An open posterior capsule makes this a riskier
- This patient’s unfortunate situation is multifactorial. Clearly, her downgaze complaints stem from the PFC in the anterior chamber. This can be addressed by removal, most preferably at the slitlamp, before other interventions, as the PFC will likely migrate in the posterior segment with the patient in the reclining position and would require a combined approach with the vitreoretinal team to remove. With a small retained bubble posteriorly, a combined vitreoretinal and anterior segment approach is reasonable, although it often comes with logistical challenges. The recurrent iritis might be exacerbated by the sharp anterior edge of the AcrySof MA30BA IOL rubbing against the iris surface. This could be addressed by synechialysis, performed bluntly or using intraocular 23-gauge microscissors, as needed, combined with repositioning the IOL optic through the posterior capsule opening, IOL exchange for a round anterior edge IOL, or both. Pupil cerclage would prevent subsequent optic capture of the iris. The reflections off the anterior surface of the IOL may be less cosmetically disturbing with a pupil repair procedure, reducing the aperture by pupil cerclage (or imbricating) sutures, IOL exchange, or both. The AcrySof MA30 series IOLs had only 5.0 diopters of power on the anterior surface and thus had maximum reflectivity. Selection of an IOL that has a higher amount of power on the anterior surface would reduce the reflection from the third Purkinje–Sanson image, reducing the perceived reflection. Alternatively, an IOL with a lower index of refraction would also mitigate this cosmetic issue, although I would be reluctant to place a silicone-based IOL in an eye with a history of retinal detachment and iritis. Whether the altered anterior surface of a presbyopia-correcting multifocal IOL would reduce the cosmetic reflections has not been studied, although it is an interesting potential speculation to discuss with the patient if she is otherwise inclined toward such an IOL. The cataract in the fellow eye should be addressed only after the issues in the first eye have been satisfactorily resolved. In the second-eye cataract surgery,
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007
CONSULTATION SECTION
1687
all efforts should be directed at placement of a posterior chamber IOL within the confines of the capsular bag, with the capsulorhexis margin overlapping the edge of the IOL. Intraoperative use of carbachol (Miostat) will keep the pupil small for the first few days. Because synechias typically form only to the capsule and not the optic, keeping the pupil margin only over the optic surface for the first postoperative days, when inflammation is highest, will reduce the chance for posterior synechia formation in the second eye.
- In this interesting case, I would start by treating the right eye. First, I would remove the PFC bubbles in the anterior chamber by aspiration with (or without) the help of an OVD. This should be fairly easy. At the same time, I would reposition the IOL and use Miostat intracamerally. After a period of stabilization (8 to 12 weeks), I would recommend phacoemulsification and IOL implantation in the left eye with a close follow-up and higher topical steroid doses for a longer period until vision stabilizes.
Michael E. Snyder, MD Cincinnati, Ohio, USA
Gu¨nther Grabner, MD Salzburg, Austria
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007